Opportunities For Cost Savings In Corrections Without .

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2013. The Urban Institute. All rights reserved.The views expressed are solely those of the authors and should not be attributed to the UrbanInstitute, its trustees, or its funders.


CONTENTSFOREWORD . 1ACKNOWLEDGMENTS. 2SECTION 1: SUMMARY . 3THE ISSUE . 3Why Is So Much Money Spent?. 3MOST PROMISING COST-REDUCTION APPROACHES . 4Approaches that Reduce Inmate Need for Health Care . 5Approaches that Reduce Cost of Health Care per Inmate Treated . 7STUDY LIMITATION. 8SECTION 2: DETAILED ANALYSIS . 9REDUCE DEMAND/NEED FOR MEDICAL CARE. 11Improve Health of Inmate Population. 11Reduce Unnecessary Consumption of Medical Services . 12Divert/Release Sick Individuals. 15REDUCE THE COST FOR TREATING AN INMATE . 17Reduce Cost of Pharmaceuticals . 17Reduce Cost of Using Outside Medical Care . 20Use In-House Medical Services When Less Expensive . 22Tighten Contracting and Auditing . 25SYNERGISTIC APPROACHES TO HEALTH CARE COST REDUCTION. 27METHODOLOGY AND CAVEATS. 28REFERENCES CITED . 31APPENDIX. 34

Opportunities for Cost Savings in Corrections without Sacrificing Service Quality:Inmate Medical CareFOREWORDFor many state and local governments, the recent economic crisis in the United States has meantdeclining revenues at a time when demand for services is at its highest. Although budget constraintshave forced many jurisdictions to institute painful cuts, some agencies have been able to developstrategies that trim spending while also maintaining—and often improving—the services on which somany constituents depend.The state and local governments have individually developed ways to reduce costs of one or moreaspects of their services without sacrificing the quality of the service often do not have time todocument or disseminate their cost saving approaches. And many governments do not have adequatestaff time to find these potentially transferable ideas or to evaluate them.The Urban Institute is seeking to identify promising approaches that have been tested in at least onejurisdiction and that have reduced costs without sacrificing service quality—and then to share theresults nationally. This report addresses inmate health care costs incurred by local and state correctionalfacilities.This current series of reports also contains two other opportunities for saving cost without sacrificingservice quality: reducing police responses to false alarms and reducing police vehicle fuel consumption.The reports on these other two areas also are available from the Urban Institute.COST SAVINGS IN INMATE HEALTH CAREPage 1

ACKNOWLEDGMENTSThe authors wish to thank the following individuals for being particularly helpful in guiding, reviewing, orotherwise contributing to this study.Harry Hatry, Director, Public Management Program, Urban InstituteJohn Roman, Justice Policy Center, Urban InstituteKamala Malik-Kane, Justice Policy Center, Urban InstituteTom Hoey, Deputy Director, Department of Corrections, Washington, D.C.Tom Riemers, Administration and Program Director, Inmate Health Services, Florida StateDepartment of CorrectionsCOST SAVINGS IN INMATE HEALTH CAREPage 2

OPPORTUNITY FOR CORRECTIONS COST SAVINGS WITHOUT SACRIFICINGSERVICE QUALITY: INMATE HEALTH CAREThis report is organized into two sections. The first is essentially an executive summary for seniorcorrectional managers, central administration officials, and elected officials. The second section isintended for the practitioners of each service or those interested in understanding the approaches ingreater depth.SECTION 1: SUMMARYThis report focuses on ways to reduce inmate health care costs without sacrificing the quality of inmatehealth care. It considers health practices in local jails and state and federal prisons. 1THE ISSUETypically 9 to 30 percent of corrections costs go to inmate health care. This amounts to hundreds ofmillions of dollars nationally, and is an aspect of corrections about which the public and manydecisionmakers are largely unaware. Inmate health care costs are high in both prisons and jails.In Washington, D.C., for example, inmate medical services in its jail cost about 33 million in 2012, aquarter of its corrections budget. 2 This does not include the cost of sending corrections officers to guardprisoners who receive medical treatment outside the jail. On average, D.C. tax payers spend about 30 aday per inmate for medical, dental, psychiatric, and vision care.Can these costs be substantially reduced? This report identifies a number of opportunities forcorrections agencies to save inmate health care costs and, very importantly, without sacrificing servicequality.Why Is So Much Money Spent?Prisons and jails are required to provide health care to inmates at a level comparable to the care theycould receive in the community if not incarcerated. It is considered an Eighth Amendment issueregarding cruel and unusual punishment, affirmed by the Supreme Court (Estelle v. Gamble 1976).Corrections institutions that do not provide adequate levels of care can be and have been sued, oftenfor millions of dollars.Another reason for the attention given to inmate health care is that public health and correctionalstakeholders increasingly view jails as a public health opportunity to affect: the course of various epidemics1The term “inmate” sometimes is used to refer to jails, and “prisoner” to prisons. We will use the terms “inmate”and “prisoner” interchangeably in this report, which is common lay usage.2Schroth 2009.COST SAVINGS IN INMATE HEALTH CAREPage 3

factors that contribute to criminal behavior and the cycle of repeated incarceration, such asuntreated mental illnessthe progression of disease so that chronic conditions can be managed in a more cost-effectivemanner when the inmate is released in the community or locked up again.Inmates typically receive a more or less comprehensive physical examination upon entry to a jail orprison. Thereafter, they are treated as needed. Some corrections institutions provide annual physicalsfor inmates incarcerated for more than a year. Medical care usually includes physical, mental, dental,and eye examinations. Sometimes prisoners are sent home from prisons or jails with medical supplies,such as AIDS medications, to continue treatment after release.MOST PROMISING COST-REDUCTION APPROACHESMany jails and prisons, probably most, are highly conscious of the high cost of medical care. Many havealready implemented a number of approaches to reduce costs while maintaining or improving inmatehealth outcomes, such as use of in-house dialysis, telemedicine for radiology, and group pharmaceuticalpurchasing contracts. 3This report lays out ways that departments of corrections can consider to reduce inmate medical costswithout affecting high standards for inmate medical services. Strategies for cost savings are presentedthat might be used by a department of corrections directly or included in contracts for outsourcinginmate health care. One or more prisons or jails across the nation use each strategy identified. Weidentified them from Internet searches and discussions with experts in the field, with the exception ofone or two approaches we suggested ourselves.Many of the approaches profiled in this report have been developed by federal and state prisons, whichhandle a different population of inmates from those of a typical municipal D.C. jail. Prisons typically havelonger lengths of stay and minimal contact with the community. In contrast, jails often experience highturnover of inmates. Many jail inmates have short stays and are booked and released several timeswithin a year. We nevertheless present ideas from both jails and prison systems because most of theircost-saving approaches seem relevant to each.In reviewing cost-reduction approaches, we used the following criteria to identify the potentially mostrelevant and actionable strategies: Cost-savings potential (net after start-up costs) Impact on service quality Transferability (to many prison and jail systems) Impact on staff (such as health and safety of corrections officers) Impact on the community (such as health and safety of citizens, effects on inmates’ families)Data were not always available to assess all of these impacts quantitatively, but they were considered atleast qualitatively.3Washington, D.C., DOC is one example of a jail system that has implemented these and other approaches.COST SAVINGS IN INMATE HEALTH CAREPage 4

Cost-reduction approaches for inmate health care are grouped here into two major categories. The firstgroup are approaches that reduce the amount of medical care needed, such as by preventive measuresand reducing unnecessary medical visits. These approaches reduce frequency of visits to medical care orthe severity of ailments that need treatment.The second group of approaches includes those that reduce the cost of health care per inmate treated,such as providing more care in house to reduce transportation and guard costs for external visits tohospitals.Exhibit 1 lists the approaches that appear most promising within each major category. Section 2 of thisreport describes these and other approaches in more detail, along with examples of their use and costsavings.Exhibit 1: Approaches to Consider to Reduce Inmate Health Care CostsApproaches that reduce inmate need for health care Screen inmates on intake, and treat diseases and conditions found (to prevent spread and toreduce severity, and hence levels of treatment needed later on.)Expand utilization management (screening requests for hospitalization and other services).Require co-payments for medical visits.Allow direct purchase of over-the-counter drugs by inmates.Provide court reminders for those arraigned but not yet jailed (to reduce unnecessary jail time).Approaches that reduce cost of health care per inmate treated Expand use of telemedicine. Reduce nurse time dispensing medications. Continue to identify less expensive yet effective medications, for physical and mental ailments. Eliminate 24-hour services where not needed. Base new health care contracts at least in part on inmate population size.Each of the above approaches is described briefly below. Most of these approaches are used in multipleprisons or jails. All are likely to be usable elsewhere. For some cost-reduction approaches, one can beconfident that they have little or no impact on inmate health either because they lower the cost of theservice without altering the service itself (e.g., purchasing pills at a lower unit-cost price) or because theapproach has been vetted in the general population (e.g., use of generic drugs versus brand namedrugs). For other approaches, more formal evaluation of their health impacts would be desirable.Approaches that Reduce Inmate Need for Health Care Medically screen inmates upon intake. A comprehensive medical and psychological exam whenprisoners first arrive is the critical first step to head off epidemics and to reduce severity ofuntreated illnesses and conditions. Many prisoners have psychological problems and addictionsthat are as important to identify and treat as physical illnesses. Inmates often immediatelybenefit from treatments, especially on their previously unknown or untreated conditions.It is difficult to quantify how much health care cost savings are ultimately realized withoutundertaking comparisons before and after implementing such screening, which we could notCOST SAVINGS IN INMATE HEALTH CAREPage 5

find if it has been don